Application for Admissions: Cape Cod Community College

APPLICATION

FOR ADMISSION

Cape Cod

Community

College

www.capecod.edu

Cape Cod Community College

2240 Iyannough Road, West Barnstable, MA 02668-1599

Fall 20__ Spring 20__

______________________________________________________________________

Last First Middle initial (maiden/former name)

_____________________________________________________________________________________________

____________________________________________________________________

______________________________________________________________________

P.O. Box # or Number & Street

______________________________________________________________________

City/Town State Zip

Primary Tel. ( ) ________________________ Secondary Tel. ( ) _________________________

Landline Cell Work Landline Cell Work

Male Female

4. Social Security Number

*Required in order to receive 1098T

tax statement and nancial aid.

5. Date of Birth

6. Citizenship

The college is authorized under federal law to

enroll nonimmigrant students.

Month Day Year Age

I am a US Citizen: Yes No

I am a Resident Alien/Refugee:

Yes No

If yes, list Alien Registration #_____________________________________

I have applied for Resident Alien status: Yes No

(Attach a copy of I-797 Notice of Action form or a letter from attorney)

I am an International Student and would like to apply for an I-20/F-1 Visa

Yes No

(Please contact the Admissions Office for additional requirements)

_____________________________________________

Place of Birth / State / Country

2. Full/Legal Name

(Including Jr, Sr, II, etc.)

Preferred First Name

3. Mailing Address

Intended Semester of Entry

PLEASE PRINT OR TYPE

7. Race/ Ethnicity

Please help us comply with state and federal

regulations by responding to the items at right.

Note: This information has no bearing on

admissions, employment, financial aid or other

decisions; however, it allows us to apply for

resources to help support our students.

a. Do you consider yourself to be Hispanic or Latino (i.e., Cuban, South or Central American, or of other

Spanish speaking culture or origin)?

Yes No

b. Select one or more of the following racial groups to describe yourself:



American Indian or Alaskan Native Asian Black or African American

Cape Verdean Hawaiian Native or Pacific Islander White/Caucasian

8. I am a veteran, or current

active duty member of the United

States Armed Forces.

Yes No

9. Highest diploma or

certificate(s) received

Associate in Arts (AA)

Associate in Science (AS)

Certificate (CRT)

High School Diploma (HS)

General Ed. Diploma (GED/HiSET)

Bachelor of Arts (BA)

Bachelor of Science (BS)

Masters (M)

10. Have you ever applied

to this college?

11. Have you ever regis-

tered for classes at this

college?

Yes No If yes, _____________________________________________________________

Semester Year

Yes No If yes, _____________________________________________________________

Semester Year

12. To be admitted to a degree or certicate program, you must have earned a high school diploma or a GED/HiSET. Students

who graduated from a Massachusetts public high school since 2003 must have successfully completed all MCAS requirements.

You must submit an ofcial high school transcript/GED/HiSET certicate ONLY IF you:

• Are a current high school senior, or

• Have not yet completed your HiSET coursework or examinations at the time you submit your application, or

• Are an applicant to a selective health program (Nursing, Dental Hygiene, Diagnostic Technician, Medical Assisting, or

Medical Interpreter), or

• Are an international applicant requiring an F-1 student visa (Please contact the Admissions Office for additional requirements)

High School last attended: _______________________________________________________________________

High School city/state: ___________________________________________________________________________

Did/will you earn a High School diploma? Yes No

Did/will you earn a GED/HiSET? Yes No

Date of High School diploma or GED/HiSET certicate is/will be: _______________ (month) _______________ (year)

You must choose one of the following:

I graduated from high school before the year 2003.

I earned a GED/HiSET.

I completed high school in the year 2003 or later and I met MCAS requirements.

I completed high school in the year 2003 or later and I earned a Certicate of Attainment.

I graduated in the year 2003 or later from a school that did not require MCAS.

(only private schools or public high schools outside of Massachusetts)

1. _

_______________________________________________________________________________________________________________________

Name of school Attended (month/year - month/year) Graduated ___ Yes ___ No

__________________________________________________________________________________________________

City, State, Zip Evaluate for transfer credit ___Yes ___No

2. _____________________________________________________________________________________________________________

Name of school Attended (month/year - month/year) Graduated ___ Yes ___ No

__________________________________________________________________________________________________

City, State, Zip Evaluate for transfer credit ___Yes ___No

3. _____________________________________________________________________________________________________________

Name of school Attended (month/year - month/year) Graduated ___ Yes ___ No

__________________________________________________________________________________________________

City, State, Zip Evaluate for transfer credit ___Yes ___No

4._____________________________________________________________________________________________________________

Name of school Attended (month/year - month/year) Graduated ___ Yes ___ No

__________________________________________________________________________________________________

City, State, Zip Evaluate for transfer credit ___Yes ___No

13. List all colleges or

universities attended

or attending. Please specify

semester and years of attendance.

Submit official transcripts of all previous post-

secondary courses. Failure to list all colleges

attended is grounds for rejection or dismissal.

14. How did you first

become aware of Cape

Cod Community College?

High school guidance counselor/teacher Newspaper ad

CCCC alumnus Radio ad

Human service agency CCCC Web site

Friend or relative Internet

Social Media CCCC admissions representative

Pandora Other _____________________

15. We strongly

encourage you to apply

for Financial Aid.

If you need assistance with your

financial aid application or college

financial aid planning, our

Financial Aid Office staff is

available to assist you.

Please select the option below that best describes your plans to complete a FAFSA. This information will have

no impact on your acceptance to the College. (Our FAFSA code number is 002168).

I am prepared to complete the FAFSA.

I need help from the Financial Aid Office to complete the FAFSA.

I have already completed the FAFSA.

I do not plan to apply for financial aid.

Program to which you are applying.

AA=Associate in Arts Degree, AS=Associate in Science

Degree, CT=Academic Certificate

16. My Ultimate Career Goal ______________________________________________________________________________________

Please select only one Academic Focus Area, Academic Program, or

Academic Certificate Program

Academic Focus Areas are collections of academic programs that have com-

mon or related content. If you are interested in a specific area of study, but

unsure of the specific program in which to enroll, an Academic Focus Area will

provide the basic coursework shared between each related program.

ACADEMIC CERTIFICATE

PROGRAMS

Short-term areas of study:

Alcohol/Substance Abuse Counselor Assistant (CTADA)

Alcohol/Substance Abuse Counselor II (CTADC)

Architectural Computer Drafting (CTADR)

Bookkeeping Clerk (CTBKE)

Computerized Accounting (CTCPA)

Construction Management (CTCMG)

Construction Technology* (CTCTH)

Corrections (CTCOR)

Customer Service (CTCSV)

Fire Officer Development* (CTFOD)

Graphic Design (CTGDC)

Homeland Security (CTHLS)

Human Services (CTHUS)

Law Enforcement (CTLAW)

Paralegal* (CTPAR)

Robotics & Manufacturing (CTRMA)

ALLIED HEALTH

Diagnostic Technician* (CTDTE)

Medical Assisting (CTMEA)

Medical Interpreter* (CTMIN)

AVIATION

Airframe (CTAMA)

Power plant (CTAMP)

EARLY CHILDHOOD EDUCATION

Infant and Toddler (CTECI)

Preschool (CTECP)

ENVIRONMENTAL TECHNOLOGY

Coastal Zone Management* (CTCZM)

Enviro. Site Assessment* (CTENS)

Geographic Info. Systems* (CTGIS)

Photovoltaic Technology* (CTEPT)

Small Wind Technology* (CTESW)

Solar Thermal Technology* (CTEST)

Water Supply* (CTWAS)

HORTICULTURE

Horticulture* (CTHOR)

Landscape Const. Tech* (CTLCT)

Landscape Maint. Tech* (CTLMT)

Horticulture Technician* (CTHRT)

HOSPITALITY

Culinary Arts (CTCAO)

INFORMATION TECHNOLOGY

Administrative Assistant: General Office (CTITA)

Administrative Assistant: Medical Office (CTITM)

Medical Coding and Billing (CTMCB)

Medical Receptionist (CTMER)

Networking (CTNET)

PC Service Technician (CTPST)

Prog. for Computer Science (CTPCS)

Security Penetration Testing (CTSPT)

Web Design (CTITW)

17. Academic Offerings – Please select the Academic Focus Area, Academic Program, or Academic Certificate

ACADEMIC FOCUS AREAS

BEHAVIORAL/SOCIAL SCIENCE FOCUS (FABSF)

History (AAHST)

Human Services (AAHMS)

Philosophy (AAPHI)

Political Science (AAPSC)

Psychology (AAPSY)

Sociology/Anthropology (AASOC)

BUSINESS FOCUS (FABNF)

Business Administration (ASBTS)

Business Administration,

Hospitality Management

(ASHMC)

Information Technology (ASINT)

Information Technology, Admin. Assistant-General (ASITA)

Information Technology, Admin. Assistant-Medical (ASITM)

Information Technology, Security Penetration Testing (ASSPC)

EDUCATIONAL FOCUS (FAEDF)

Early Childhood Education-Career (ASECE)

Early Childhood Education-Transfer (ASETC)

Education (AAEDU)

Elementary Education (AAEED)

FINE AND PERFORMING ARTS FOCUS AREA (FAFPF)

Graphic Design (AAGPD)

Visual Arts (AAART)

Performing Arts (AAPFM)

HEALTH SCIENCE FOCUS AREA (FAHSF)

Health Science (AAHSC)

Dental Hygiene (ASDHY)

Nursing - Day (ASNUR)

Nursing - Evening (ASNUE)

even years only

Nursing - LPN to RN (ASNLP)

must already be an LPN

HUMANITIES FOCUS AREA (FAHMF)

Communications (AACOM)

English (AAENG)

General Studies (AAGEN)

Liberal Arts (AALIB)

Media Studies (AAMED))

PUBLIC SAFETY FOCUS AREA (FAPSF)

Criminal Justice (ASCRJ)

Fire Science (ASFSC)

STEM FOCUS AREA (FASTF)

Aviation Maintenance Technology (ASAMT)

Biology (AABIO)

Chemistry (AACHM)

Computer Science (AACSC)

Engineering Technology & Advanced Manufacturing (ASEAM)

Environmental Studies (AAENV)

Environmental Technology (ASEVT)

Mathematics (AAMAT)

Physics (AAPHY)

18. MASSACHUSETTS COMMUNITY COLLEGES – IN-STATE TUITION ELIGIBILITY FORM

Last Name _________________________________First Name ________________________________ MI _________

Street Address _______________________________ City ____________________State ____ Zip Code __________

SSN# or Student I.D. Number __________________________________ Date of Birth _________________________

Are you a U.S. Citizen? Yes No If NOT, please complete the following:

Are you a Permanent Resident? Yes No (If yes, list alien registration #:_____________________)

If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:

________________________________________________________________________________________________

Please check the in-state or reduced tuition eligibility category that applies to you:

I have been a Massachusetts resident for six (6) continuous months and intend to remain here.

As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall

present to the institution upon request. These documents* are dated within one (1) year of the start date of the academic

semester for which I seek to enroll (except possibly for my high school diploma). The institution reserves the right to make

any additional inquiries regarding the applicant’s status and to require submission of any additional documentation it

deems necessary. Please check-off those documents you possess as proof of your intent to remain in Massachusetts.

Valid Driver’s license Utility bills* Employment pay stub*

Valid Car registration Voter registration* State/Federal tax returns*

Mass. High School Diploma Signed lease or rent receipt* Military home of record*

Record of parents’ residency for unemancipated person* Other ________________

I am an eligible participant in the New England Board of Higher Education’s Regional Student Program.

I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts.

I do not qualify for in-state tuition eligibility at this time.

Certication of Information: I certify that this information is true and accurate. I understand that any misrepresenta-

tion, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a

tuition refund.

Applicant Signature: _________________________________________________________________ Date________

Parent/Guardian Signature (Applicant is Under 18 Years Old): ______________________________________ Date________

DON’T STOP HERE . . .

Remember to complete and sign the application on page 6 of this form.

FOR OFFICIAL USE ONLY – DO NOT WRITE IN THIS BOX

I have reviewed the above information in order to determine this individual’s eligibility to receive the in-state tuition rate. Based on my

review I have determined that this individual:

_____ IS eligible for the in-state tuition rate.

_____ IS NOT eligible for the in-state tuition rate.

_____ I am unable to make a determination at this time. The following additional information has been requested

from the applicant:

Authorized College Personnel: ____________________________________________________ Date __________________________

19. Parent / Guardian 1

______________________________________________________________________________________________________________________________

Name

____________________________________________________________________________________________________________________________ _

Address City, State, Zip

Does your Parent /Guardian 1 have a bachelor’s degree or higher? Yes No

20. Parent / Guardian 2

______________________________________________________________________________________________________________________________

Name

____________________________________________________________________________________________________________________________

Address City, State, Zip

Does your Parent /Guardian 2 have a bachelor’s degree or higher? Yes No

21. INFORMED CONSENT:

The information requested in this application will be used and held in confidence under provisions General Law Chapter 66A for the purpose of determining your

eligibility for admission to Cape Cod Community College. This information may be used by the various offices at the College and will become your permanent

record maintained by the Registrar of the College. Any inquiries concerning the methods of holding data and types of data to be held or your rights to object should

be directed to the Vice President of Academic and Student Affairs. All materials submitted become property of the College.

Photo/Video at Cape Cod Community College: Cape Cod Community College reserves the right to take photographs and videos of students, staff,

and visitors, anywhere the College functions, and at all College-sponsored events. All images taken for or by the College are the property of Cape Cod Community

College, a non-profit organization, and may be used for public information, marketing and promotional purposes.

I have read and understand the Informed Consent Statement above and agree to the uses of data therein.

PLEASE SIGN: Signature ___________________________________________________________________________ Date______________________________________

Send application to:

Admissions Office

Cape Cod Community College

2240 Iyannough Road

West Barnstable, MA 02668-1599

The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act requires colleges and universities to publish an annual security report. The report contains information

regarding campus security including such topics as: emergency procedures, crime prevention, law enforcement authority, crime reporting policies, sexual assault prevention, disciplinary procedures and other matters of importance related to

security on campus. It also contains crime statistics for the previous three calendar years. You can find Cape Cod Community College’s crime statistics online at www.capecod.edu/web/public-saftey . To request a printed copy Jeanne Clery

Disclosure report, please call 508-362-2131 ext. 4302 or stop by the Public Safety Office.

Affirmative Action

Cape Cod Community College is an Affirmative Action/Equal Opportunity employer. We encourage applications from individuals who will enrich and contribute to the cultural and ethnic diversity of our College. Cape Cod Community College does

not discriminate on the basis of race, color, national origin, sex, disability, religion, age, veteran status, genetic information or sexual orientation in its programs and activities as required by Title IX of the Educational Amendments of 1972, the

Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, Title VII of the Civil Rights Act of 1964 and other applicable statutes and College policies. Cape Cod Community College prohibits sexual harassment, including

sexual violence.

Inquiries concerning the application of anti-discrimination laws may be referred to the Affirmative Action Coordinator, Title IX Coordinator, Coordinator of Disability Services, the Massachusetts Commission Against Discrimination or the United

States Department of Education’s Office for Civil Rights.

Inquiries may be directed to:

Affirmative Action Office

1-508-362-2131, ext. 4306

O’Neill Center for Disability Services

1-508-362-2131, ext. 4337

Title IX Coordinator

1-508-362-2131, ext. 4618

Filing Complaints

For purposes of filing federal charges of discrimination under Title IX of the 1972 Educational Amendments, Section 508 of the 1973 Rehabilitation Act, or Title VI of the 1964 Civil Rights Act, students may contact:

Federal Office for Civil Rights

McCormack Post Office and Court House

Post Office Square

Boston, MA 02109

Cape Cod Community College, 2240 Iyannough Road, West Barnstable, MA 02668-1599

Criminal Offender Record Information (CORI) and Sex Offender Registry Information (SORI) Checks

In order for a student to be eligible to participate in an academic, community or clinical program that involves potential unsupervised contact with children, the disabled, or the elderly, the student may be required to undergo a Criminal Of

fender

Record Information (CORI) check and/or a Sex Offender Registry Information (SORI) check. Students found to have certain criminal convictions or pending criminal actions will be presumed ineligible to participate in such activities. The College

is authorized by the Commonwealth’s Department of Criminal Justice Information Services, pursuant to Massachusetts General Laws, Chapter 6, Sections 167-178B, to access CORI records. Sex Offender checks shall be performed pursuant to

Massachusetts General Laws, Chapter 6, Sections 178C-178P.

For more information regarding the College’s CORI/SORI check process, please contact the Dean of Enrollment Management and Advising Services 508-362-2131 ext. 4315.